Intrauterine contraceptive devices Flashcards
Which women are most appropriate users of the IUS?
- Suitable for all women of reproductive age until contraception no longer required
- First-line medical treatment for HMB and will reduce dysmenorrhoea
- Can be used for women with undetectable bHCG and a history of trophoblastic disease
Who is the IUS not suitable for?
- Unexplained vaginal bleeding
- Post-partum women between 48 hours and 4 weeks post-delivery
- Post-partum or post-abortion sepsis
- Persistently elevated b-hCG or malignant gestational trophoblastic disease
- Cervical cancer awaiting treatment
- Endometrial cancer
- Current PID
- Current CT or GC
- Known pelvic TB
- Known serious cardiac conditions or arrhythmias where a vasovagal collapse may have serious consequences
- HIV positive with a CD4 count <200
What is the MOA of IUS?
- Alters cervical mucus, inhibits sperm penetration and migration
- Prevents endometrial proliferation, this prevents implantation if fertilization occurs
- Progestogen may affect sperm motility and function
- Ovulation may be suppressed
What is the efficacy of the IUS?
- Failure rate of up to 2 in 1000 over 5 years
What are some advantages of the IUS?
- Long-acting and independent of sexual intercourse
- Not affected by liver enzyme inducing drugs
- reduces menstrual blood loss
- May prevent fibroid formation
- reduces incidence of dysmenorrhoea
- reduces risk of ectopic pregnancy
- reduces incidence of PID
- Mirena is licensed to be used for HRT progestogenic component
- May protect against endometrial hyperplasia
What fraction of women become amenorrhoeic with the IUS?
One-quarter of women will be amenorrhoeic by year 3 using the Mirena
What are some disadvantages of the IUS?
- Can cause irregular/prolonged bleeding in the first 3 months
- May be expelled or displaced
- May be painful on fitting
- Failure to fit in 1-2% of cases
- Small increased risk of PID immediately after fitting
- may develop functional ovarian cysts
- Non-visible threads requiring TVUSS
- Some progestogenic symptoms in the first few months
- In the event of IUS failure, 25-50% of pregnancies will be ectopic, although the overall risk of ectopic pregnancy is lower than the general population
When can the IUS be inserted without requirement for 7 days of additional contraceptive precautions?
- Up to an including day 7 of natural menstrual cycle
- Within 48 hours post-partum following childbirth
- Within 7 days following abortion, miscarriage, ectopic pregnancy or gestational trophoblastic disease
- Switching from CHC on D1 of HFI or week 2 or 3 of CHC
- At any time switching from the desogestrel POP, injectable or implant (NOTE will need additional cover on other POPs)
- If inserting the IUS up to and including day 7 of cycle after IUD
- Switching from IUS and no sexual intercourse for 7 days prior to the changing of IUS
When may an IUS remain in place till in women >45?
- If a Mirena is fitted in women of 45 years or older for contraception, it can remain in place until aged 55
- If a Mirena is fitted in women of 45 years or older for HMB only, it can remain in place as long as it is effective
What to advise if threads cannot be felt?
Additional contraception such as condoms should be used. Make appointment with GP or sexual health clinic.
Is there any delay in return to fertility with IUS?
No
How can you manage spotting or bleeding on the IUS?
CHC can be used for 3 months either cyclically or continuously
What is the perforation rate for IUS/IUD insertion?
up to 2 per 1000
What is the expulsion rate for IUS/IUD insertion?
1 in 20; highest in first 3 months post-insertion and during menstruation
What is the infection risk for IUS/IUD insertion?
6-fold increased risk of PID in the first 20 days post-insertion
In which patients are IUDs most appropriate for?
- If wanting non-hormonal method of contraception
- If requires EC
- Can be used for women with undetectable b-hCG and a history of trophoblastic disease
Who may not be suitable for IUDs?
- Unexplained vaginal bleeding
- Post-partum and post-abortion sepsis
- Post-partum between 48 hours and 4 weeks post-delivery
- Persistently elevated b-hCG or malignant gestational trophoblastic disease
- Cervical cancer awaiting treatment
- Endometrial cancer
- Current PID
- Current GC or GC (unless asymptomatic and Rx given)
- Known pelvic TB
- Known serious cardiac conditions or arrhythmias where a vasovagal collapse may have serious consequences
- HIV with CD4 <200
What is the MOA of IUDs?
- Prevents implantation
- Toxic to sperm and ova
What is the efficacy of the IUD?
Failure rate of around 2% after 10 years and 0.1-1% after the first year of use.
What are the advantages of the IUD?
- Long term, can be up to 10 years
- No delay in return to fertility
- Non-hormonal, no hormone side-effects
- Effective immediately
- Non-intercourse related
- Not affected by enzyme inducing medications
- Can be used when breastfeeding
- Most effective method of EC
- May give up to 50% protection against the development of endometrial cancer
What are the disadvantages of the IUD?
- May cause menstrual irregularities, IMB and spotting
- Pain or discomfort
- Failure to fit
- Heavier periods
- 1 in 20 IUDs expelled - most likely to occur within the first 3 months after fitting
- Uterine perforation
- If pregnancy does occur, approximately 15% will be ectopic. Absolute risk of ectopic pregnancy lower than background population.
When is additional contraception required on starting IUD?
Never
Is there any delay to fertility with IUD?
No
How would you manage spotting or bleeding with IUD?
- Spotting or light bleeding commonly experienced during the first 3-6 months of IUD use, but it usually decreases with time
- Exclude STIs, pregnancy and gynaecological pathology
- Tranexamic acid 1g TDS for D1-4 of bleeding +/- NSAID (ibuprofen or mefenamic acid)
- If heavy bleeding is unacceptable or causes anaemia, discuss changing the contraceptive method to an IUS or an alternative LARC
